THE MENTAL HEALTH OF HEALTH PROFESSIONALS: SUICIDE AND SUBSTANCE ABUSE

The Victorian Institute of Forensic Medicine has recently published a poignant article which I have enclosed regarding the mental health of our own profession- healthcare professionals. You can access the cases referenced in this commentary here>>

The enclosed expert commentary on the topic is by Dr Kym Jenkins MB.ChB,FRANZCP, MPM, MEd, GAICD Consultant Psychiatrist,Medical Educator President, Royal Australian and New Zealand College of Psychiatrists (RANZCP)Ex-Medical Director, Victorian Doctors Health Program (VDHP).

The three cases discussed in this issue bring home in the most painful way that as health professionals we are not immune to mental health problems, including substance use disorders that can lead to suicide.

In fact, there are multiple factors that make us more vulnerable. Being a healthcare worker is inherently stressful: we cannot change that we look after sick people who don’t always get better, that we see horrific sights and hear patients telling us unspeakable stories. We are constantly reminded of our own mortality.

There are days when as health professionals we go home and cry that we have lost a patient, feeling that we have let them and their families down, and days when we feel supersaturated with other peoples’ problems. Unless we lose our humanity, these moments are inevitable. However, we can try to do whatever we can to modify the effect these sorts of events have on us and our colleagues: we can ensure there are enough other things in our lives to buffer these potential traumas and that we act collegially, looking after and supporting each other.

We do ourselves a disservice if we continue to focus too strongly on the workplace and “how tough the job is” as a cause for ill health. It is vitally important to be mindful that as human beings we experience stressful major life events outside of our careers and can get the same (mental) illnesses as the general population. We do ourselves (and any struggling colleagues) a disservice if we forget that none of us chose our own genetic inheritance, and we may have inherited biology that predisposes to mental illness that may manifest whatever career we had chosen.

The three cases illustrate that not all mental illness in healthcare workers is because the job is tough or the workplace is toxic, but that there are many barriers to doctors and health professionals seeking and accessing help when they need it (Jenkins 2016, Kay et al 2008).

Suicide is the only cause of death where rates for doctors are higher than for the general population.

Physicians’ health is a topic that has never before been so prominent in mainstream, social and medical media. There is evidence that physicians display elevated rates of common mental health disorders compared to the general population (Mata et al 2015). There is also increasing academic and clinical interest in the health and welfare of other health professionals particularly first responders (Harvey et al 2017). Owing to factors such as shame, stigma, denial and lack of access to confidential services, the true rates of substance use disorders in health professionals are unknown.

Lifetime prevalence of impairment from substance use for doctors has been estimated to be between 8-18% (Blondell 2005). However, it is known that when doctors enter treatment, recovery rates are greater than for the general population (McLellan et al 2008, Wile et al 2011).

Suicide is the only cause of death where rates for doctors are higher than for the general population (Torre et al 2011). Whether suicide is impulsive and reactive to an acute situation or crisis, something that has been contemplated for some time but ultimately opportunistic, or meticulously planned with “getting one’s affairs in order”, disposal of assets and a suicide note can sometimes be inferred at the inquest. It is rare though, to be able to form a valid opinion about the factors that finally led to someone taking their own life.If we are truly to understand suicide there is as much need for a psychological autopsy as for a physical autopsy. We have information about the “how” and “when” but not the “why”.

Information from those who have survived a suicide attempt is a poor approximation here. It is contentious how much someone’s profession or work stressors play in their suicidal ideation or final decision to take their life. The idea that it is a predominant factor has gained much traction in recent years and there is an unsubstantiated emphasis on, and a weak evidence base for, workplace stress and mandatory reporting as a reason for suicide in doctors. It is suggested that whilst risk should not be ignored, there is more to be gained from focusing on the factors that drive the risk, on remedial factors and those amenable to treatment.

Undeniably, for health professionals, being reported to their regulatory body is extremely stressful and has been shown to be associated with high rates of suicide for doctors in the United Kingdom (Horsfall 2014).

However, a study conducted at the Victorian Doctors Health Program (VDHP) failed to support that being under investigation was a direct causal link for suicide. Analysis of files of doctors who had attended VDHP and ultimately suicided, indicated that major mental illness particularly in combination with significant substance use were factors.

Though all, except one, were recognised to be at high risk of suicide, time of suicide could not be predicted. Suicide was not temporally related to notification of the regulatory body, but more likely to be related to acute (real or perceived) separation from loved ones. Risk of suicide and risk of self-harm are notoriously difficult to predict. It is suggested that whilst risk should not be ignored (Large et al 2017), there is more to be gained from focusing on the factors that drive the risk, on remedial factors and those amenable to treatment. Models of and access to mental health care varies across jurisdictions and between rural and metropolitan areas, as does stigma and discrimination. Some mental illnesses have very high mortality rates and there is no reason for these rates to be lower in the healthcare community.

Health professionals have greater access to the means to commit suicide and greater knowledge of what is most likely to be effective. In Australia, doctors can access help for mental illness and substance use through the Australian Doctors’ Health Network, which links directly to Statebased services. Nurses and midwives in Victoria can access help through the Nursing and Midwifery Health Program which works in association with Turning Point. Employee assistance programs are increasingly available for first responders and emergency workers. Globally, Doctors’ health services are well established in the United States, Canada, United Kingdom and Scandinavia, and interest is growing in Asia.

GETTING HELP

If you or anyone you know needs help, these telephone support services are available:

• Lifeline Australia telephone counselling 131 114 (24 hours)

• Suicide Call Back Service 1300 659 467 (24 hours)

• SANE Helpline 1800 187 263 (10am-10pm AEST)

• beyondblue 1300 22 46 36

•Perinatal Anxiety & Depression Australia 1300 726 306

• Kids Helpline 1800 551 800

• MensLine Australia 1300 789 978

• Headspace 1800 650 890

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